Foreword

This manual is a technical, procedural document. Its companion publication, Accreditation Without Borders, tells the full narrative history of Accréditation Sans Frontières (ASF) — from the founding decision made in Georgia in 2014 through to the establishment of ASF itself and the ASF International Standards Council in 2020. That history is not repeated here in full; this manual assumes it and builds forward from it.

What follows is the complete governing methodology for how ASF develops, reviews, revises, and retires the standards it publishes — covering legal foundation, governance, human resources, conflict of interest, the revision cycle itself, reporting, appeals, and the full chain of documents a Council officer actually uses to run this process, from the first call for a Revision Panel member through to a published, version-controlled standard.

How to Use This Manual

This manual governs three distinct but structurally parallel tracks of ASF's work: the accreditation of healthcare organizations against ASF's published standards — the seven current documents covering Hospital, Ambulatory Clinic, Long-Term Care, Primary Health Clinic, Fitness & Wellness, Telemedicine, and Home Care settings — the accreditation of ASF's own surveyors, governed by the ASF Surveyor Training Standard, and the accreditation of training and education programs, governed by the ASF Training & Education Standards, with the specific differences for each addressed in Part IV. Wherever a procedure in this manual applies to only one of these three tracks, that is stated explicitly. Where no distinction is stated, the procedure applies equally across all three.

The manual is organized so that a reader can approach it in two ways. Read sequentially, Parts I through V build the methodology from first principles — legal foundation, then the external practice ASF's methodology is built on, then ASF's own governance, then the specific procedures for organizational and training standards respectively, then the complete document chain that ties every procedure to an actual, working document. Read as a reference, each Annex is a self-contained, usable form or template, cross-referenced back to the specific section of this manual that governs its use — set out in full in Part V, Section 18.

Part I — Foundations

1. Purpose, Scope, and Legal Status

1.1 Purpose of This Manual

This manual is the governing procedural document for the ASF International Standards Council — the standing body responsible, since Accréditation Sans Frontières (ASF) was established in 2020, for developing, reviewing, and revising every standard ASF publishes. It exists so that any Council member, panel candidate, partner organization, or external reviewing body can see exactly how a standard reaches its published form, what happens to keep it current, and what document is produced at every step.

1.2 ASF's Legal Status and Governing Law

Accréditation Sans Frontières is registered as an association d'intérêt général à but humanitaire et non lucratif (a general-interest, non-profit humanitarian association), governed by the French law of 1 July 1901 on associations. It was declared to the Préfecture de Police de Paris on 18 June 2020 (RNA n° W751257030), with its declaration published in the Journal Officiel on 27 June 2020 (Announcement n° 1340). ASF is registered under SIRET n° 88807681700012, activity code APE n° 9499Z.

ASF's registered office is at 32, Boulevard de Rochechouart, 75018 Paris, France.

ASF's founding Georgian partner, the Public Health Institute of Georgia (Georgian: საქართველოს საზოგადოებრივო ჯანდაცვის ინსტიტუტი), is registered as a non-entrepreneurial (non-commercial) legal entity under Georgian law, registration number 404407815, registered on 9 September 2011.

1.2.1 Precedence Between ASF Standards and National Law

Where a specific requirement in an ASF standard conflicts with the mandatory law or regulation of the country in which an accredited organization operates, national law governs. This is not a weakness in ASF's standards; it reflects that ASF's Council operates as described in Section 2.4 — informed by international practice, but without the legislative authority of any single state. Where such a conflict is identified, the accredited organization documents it as part of its own compliance record, and the Revision Panel treats the identified conflict as a genuine input to the standard's next scheduled review under Section 12, rather than a reason to quietly waive the requirement without record.

1.3 Relationship Between This Manual and ASF's Published Standards

This manual does not itself contain the specific accreditation criteria published in ASF's standards documents. It governs how those documents — the seven current organizational standards, any future organizational standard, the ASF Surveyor Training Standard, and the ASF Training & Education Standards — are scoped, drafted, consulted upon, approved, published, and revised.

1.4 Scope: Three Standard-Types, One Governing Manual

This manual explicitly governs all three of ASF's standard-types under a single, consistent methodology:

• Organizational standards — criteria against which a healthcare facility or organization is directly assessed. ASF's seven current organizational standards (Hospital, Ambulatory Clinic, Long-Term Care, Primary Health Clinic, Fitness & Wellness, Telemedicine, and Home Care) fall under this type.
• Surveyor training standards — criteria against which the training, certification, and ongoing competence of ASF's own surveyors is assessed, published as the ASF Surveyor Training Standard (ASF-SURV-STD-v2).
• Training and education standards — criteria against which a training program, course, or educational offering is assessed, distinct from the facility or professional that completes it. This standard-type is published as ASF Training & Education Standards (ASF-TRAIN-STD-v1), delivered in partnership with GMJ Academy, and is addressed specifically in Part IV of this manual.

Every procedure in Parts I, II, III, and V of this manual — governance, human resources, conflict of interest, the revision cycle, reporting, appeals, document control — applies identically across all three standard-types unless a specific Part states otherwise. This is a deliberate design choice: a single Council, operating under a single methodology, with distinct areas of substantive expertise feeding into its Revision Panels depending on which standard-type is under revision.

2. Governing Principles

Four principles govern every procedure in this manual. They are not aspirational language; each has specific, binding consequences set out in the sections that follow.

2.1 Accreditation Without Borders

ASF's own name states its founding principle: accreditation should be genuinely accessible across borders, not confined by the resources or regulatory maturity of any single country. In practical governance terms, this principle requires that Council and Revision Panel membership, field consultation, and the standards themselves are never developed with only one country's healthcare system as the implicit default — a requirement made explicit throughout Part III.

2.2 Non-Discrimination and Equal Opportunity

ASF's non-discrimination policy is grounded in the International Labour Organization's Discrimination (Employment and Occupation) Convention, 1958 (No. 111) — one of the ILO's fundamental conventions, in force since 15 June 1960 — and in the Convention on the Rights of Persons with Disabilities [40].

ASF does not discriminate, in Council or Revision Panel membership, in field consultation participation, or in the content of its published standards, on the basis of race, colour, sex, religion, political opinion, national extraction, social origin, age, disability, family responsibilities, sexual orientation, trade union membership or activity, language, or any other characteristic unrelated to a candidate's genuine ability to contribute to the specific role [24, 36]. Consistent with ILO Convention No. 111's own framing, this list is not exhaustive [37].

ASF's policy specifically recognizes the distinction, established under Convention No. 111, between direct and indirect discrimination [37]. Direct discrimination excludes or disadvantages a candidate explicitly because of a protected characteristic. Indirect discrimination occurs where an apparently neutral requirement — a language requirement, a specific credential, a particular meeting format or time zone — has a disproportionate, unjustifiable effect on a particular group. The Selection Procedure in Section 9 is specifically designed to be reviewed for indirect discrimination risk, not only direct exclusion.

1. Reasonable accommodation. Where a candidate or Council member's disability requires a reasonable accommodation — in meeting format, documentation format, or working arrangement — ASF provides it, consistent with the Convention on the Rights of Persons with Disabilities [40].

2. Language accessibility. Field consultation and call announcements are not confined to a single working language where this would systematically exclude practitioners in ASF's actual countries of operation.

3. No geographic or institutional gatekeeping. Eligibility for Council or Revision Panel service is never limited to ASF's existing partner organizations or prior applicants; the Call Procedure in Section 9 is specifically designed as an open, public process for this reason.

2.3 Transparency and Public Accountability

Every ASF standard is published in full and made freely available, consistent with the transparency principle stated in each standard's own foreword. This manual extends that same principle to governance itself: the composition of each Revision Panel, the outcome of every revision cycle, and the resolution of every appeal are documented and, in summary form, publicly available.

2.4 Independence of Standards Development from Assessment

Following the governance principle Health Standards Organization (HSO) adopted after consulting more than 700 stakeholders in 2016 [6], ASF keeps the development and revision of its standards organizationally distinct from the assessment of organizations against them. The Council and its Revision Panels, governed by this manual, do not conduct facility or program assessments; a separate ASF function carries out that work. This separation exists specifically to prevent the body that writes a requirement from also being the body that decides, for its own convenience, whether that requirement has been met.

Part II — The Three Foundational Methodologies

ASF's International Standards Council did not invent its methodology from first principles. It is built, deliberately and specifically, on how three established international bodies actually develop and revise the standards and guidance they publish — examined here in the order of priority ASF gives them: the World Health Organization first, the International Organization for Standardization second, and the International Society for Quality in Health Care third.

3. World Health Organization

WHO's guideline development process is ASF's primary methodological reference. It is the most procedurally rigorous of the three, built around explicit, graded evidence assessment and a genuinely staged approval structure — and it is the model ASF's own Council most directly mirrors.

3.1 The Steering Group

Every WHO guideline begins with a Steering Group, drawn from relevant WHO departments and regional offices. The Steering Group drafts the initial scope of the guideline; identifies candidate members for the Guideline Development Group (GDG) and its chair, drawing on WHO's roster of advisers and experts as well as an open call for expressions of interest; formulates the guideline's key questions in PICO format; obtains and reviews declarations of interest from candidate GDG members; and finalizes a planning proposal [15–18, 29–35].

3.2 Scoping and the PICO Framework

WHO guidelines do not begin with a draft — they begin with a small number of precisely framed questions, each specifying the population affected, the intervention or practice in question, the comparator against which it is judged, and the outcome that actually matters [29, 34]. This discipline exists specifically to prevent a guideline from attempting to answer everything at once, and to make clear, before any evidence review begins, exactly what decision the guideline is meant to inform.

At the first GDG meeting, members review and, where necessary, revise the Steering Group's draft PICO questions, then rank the outcomes associated with each question by importance — typically using a 1-to-9 scale, where 7–9 indicates an outcome is critical to the decision, 4–6 indicates it is important but not critical, and 1–3 indicates it is not important enough to influence the recommendation [29, 32]. Only outcomes rated critical or important proceed into the evidence review.

3.3 Conflict of Interest: Declaration, Disclosure, and Severity Review

Every candidate GDG member completes a written declaration of interests before an invitation to participate is finalized [33, 35]. A technical officer reviews each declaration together with a departmental director, not alone, specifically to determine whether a declared interest is serious enough to affect the individual's objective judgement, using defined severity criteria set out in the WHO Handbook for Guideline Development [18, 35]. At the GDG meeting itself, each participant verbally restates the interests already declared in writing, in front of the full group [33]. Conflicts are managed in consultation with WHO's own Office of Compliance, Risk Management and Ethics [29].

3.4 Commissioning and Assessing Evidence

Once outcomes are prioritized, the Steering Group commissions systematic reviews for each PICO question, following protocols modeled on the Cochrane Collaboration — including a defined search strategy and explicit inclusion and exclusion criteria agreed before evidence retrieval begins [30, 34–35]. Existing systematic reviews are first assessed for quality using the AMSTAR (A MeaSurement Tool to Assess systematic Reviews) checklist and for currency, before new reviews are commissioned to fill any genuine gap [30].

Evidence quality is then graded using GRADE, considering five domains: risk of bias in the underlying studies, inconsistency of results across studies, indirectness of the evidence to the actual question asked, imprecision of the effect estimate, and risk of publication or reporting bias [16, 18, 30]. Each domain can lower the confidence rating; the result is a specific, explicit certainty rating — high, moderate, low, or very low — for every critical outcome, not a single undifferentiated judgment that “the evidence supports this.”

3.5 The Guideline Development Group Meeting and Recommendation Strength

The GDG convenes — in person, virtually, or in hybrid format — to review the evidence profiles, discuss the balance of benefits and harms, and formulate recommendations. Co-chairs are proposed by the Steering Group but require the GDG's own agreement before being confirmed [31]. A recommendation's strength — strong or conditional — is determined jointly with its direction (for or against), weighing evidence certainty alongside values and preferences, feasibility, equity, acceptability, and resource implications [15, 18]. A strong recommendation signals that most decision-makers, in most circumstances, should follow it; a conditional recommendation signals genuine, legitimate room for differing decisions depending on context — a distinction ASF's own Council adopts directly in Section 12.

3.6 External Review, Final Approval, and Living Updates

A completed draft guideline is sent to an External Review Group (ERG) — a body distinct from the GDG, composed of peer reviewers with broad relevant expertise — for independent review before publication [31]. Both the initial planning proposal and the final guideline pass through WHO's standing Guideline Review Committee (GRC), which convenes monthly specifically to review guideline plans and final drafts for methodological compliance before anything is published [17, 35].

WHO increasingly treats certain guidelines as “living” documents — subject to more frequent, targeted evidence surveillance between full revision cycles, rather than left entirely static for years at a time. ASF's own three-year cycle, described in Section 12, does not adopt continuous living-guideline surveillance given ASF's current scale, but the underlying principle — that a standard's currency should not depend solely on a fixed calendar date — informs the field consultation practice in Section 12, Stage 5, which remains open to proposals at any point in the cycle, not only during the formal consultation window.

4. International Organization for Standardization

ISO is ASF's secondary methodological reference — the model for how ASF structures formal, staged consensus and mandatory periodic review across a genuinely global membership.

4.1 Technical Committees and National Mirror Committees

ISO standards are developed by Technical Committees (TCs) and Subcommittees (SCs), each open to participating national member bodies. Each participating country establishes its own “mirror committee” — a national body that reviews draft standards, develops a national position, and nominates experts to represent that position in the international TC or SC [23]. This is what allows a single ISO standard to genuinely reflect practice across more than 160 countries, rather than one dominant national perspective.

Within each TC or SC, member bodies participate either as P-members (Participating members, who vote) or O-members (Observer members, who may comment but not vote) [20]. This distinction matters directly for ASF's own Council composition in Section 8: a body's formal voice in a decision should be a deliberate design choice, not an accident of who happened to attend a given meeting.

4.2 The Six-Stage Process

Every International Standard passes through six defined stages [20–22]:

1. Proposal — a new work item is proposed and approved by the relevant TC/SC.

2. Preparatory (Working Draft) — a working group drafts the standard; successive working drafts are circulated until the group judges it ready to advance.

3. Committee (Committee Draft) — the draft is circulated to the full TC/SC membership for comment; successive committee drafts may be issued until technical consensus is reached.

4. Enquiry (Draft International Standard, DIS) — the draft is circulated to all ISO member bodies for a formal vote and comment period of several months. Approval requires at least two-thirds of P-member votes in favor, with no more than one-quarter of all votes cast negative [20, 21].

5. Approval (Final Draft International Standard, FDIS) — required only if the Enquiry stage produced technical changes; member bodies cast a final yes/no vote within a defined period.

6. Publication — the approved text is issued as a formal International Standard.

Where a document of sufficient maturity already exists — for instance, a standard already developed by another recognized body — ISO permits a “fast-track procedure” that submits the document directly to Stage 4 or 5, skipping the earlier drafting stages entirely [20]. ISO also publishes a faster-moving Publicly Available Specification (PAS) for standards with an urgent market need, approved directly by the responsible TC without the full international balloting the Enquiry and Approval stages require — typically publishable within 6–18 months rather than the 3–5 years a full International Standard usually takes [22].

4.3 Mandatory Systematic Review

Every published ISO standard undergoes mandatory Systematic Review at least every five years after publication or after its last confirmation [19, 21]. A Technical Specification or Publicly Available Specification is reviewed on a shorter three-year cycle [21]. The responsible Technical Committee has exactly three possible decisions: confirm the standard as still current, revise it, or withdraw it — with withdrawal specifically considered where a standard is not in active use by a minimum threshold of member countries [19]. National mirror committees are given up to twenty weeks to canvass domestic stakeholders before submitting their country's vote on a systematic review decision [21].

5. International Society for Quality in Health Care

ISQua is ASF's tertiary methodological reference, and the closest in scale and mission to ASF's own work — ASF has been an ISQua member since 2023 [9].

5.1 Literature Review and Drafting

ISQua's own standards-development guidance begins with a structured literature review to identify emerging themes or necessary changes since the prior edition, conducted by ISQua's International Accreditation Programme (IAP) team before any drafting begins [11].

5.2 Client and Surveyor Consultation

A draft is circulated specifically to client organizations — the accrediting bodies that use ISQua's standards to accredit healthcare organizations in their own countries — and to ISQua's own surveyors, for structured consultation [11]. This is a genuinely distinct consultation population from WHO's or ISO's: not the end healthcare organizations, but the intermediary bodies and assessors who apply the standard daily.

5.3 RUMBA Pilot Testing

Before finalization, revised standards are pilot-tested in real accrediting organizations against five explicit criteria [10–11]:

• Relevant — the criterion addresses a genuine, current quality or safety concern
• Understandable — the criterion is written so it can be consistently interpreted
• Measurable — compliance can be objectively assessed, not merely asserted
• Beneficial — meeting the criterion produces a genuine improvement in care or safety
• Achievable — the criterion is realistically attainable by the organizations it governs

5.4 The Assessment Methodology

ISQua EEA assesses an applicant organization's own standards through a desktop or remote review, typically conducted over a two-week period. The applicant submits a self-assessment tool documenting its compliance with each requirement in ISQua's Principles, alongside a copy of its own standards and supporting evidence, through ISQua EEA's online system. A team of international peer-review surveyors then independently assesses the submission [38].

Beginning with the 6th Edition of ISQua's Principles, effective from July 2026, the prior 4-point compliance rating scale was replaced by a 3-point scale, and the previous numerical scoring model for awarding accreditation was replaced by a risk-based assessment approach [9]. From October 2025, ISQua EEA also began requiring organizations to hold both standards accreditation and organizational accreditation, rather than either alone [38] — a structural change ASF's own three-pillar model in Section 6 anticipates by design, since ASF already treats standards accreditation and organizational assessment as related but organizationally distinct functions.

5.5 Accreditation Council Approval and Cycle

ISQua's Accreditation Council, acting on behalf of the ISQua Board, reviews pilot results and formally approves the revised standards [10–11]. ISQua commits to revising its own foundational guidance at least every four years [10] — a cycle ASF's own three-year commitment sits comfortably alongside, being marginally more frequent.

5.6 Principles Common to All Three Bodies

Across WHO, ISO, and ISQua — despite genuinely different sectors, scales, and governance structures — four principles recur, and each is load-bearing in ASF's own methodology:

• A structured, documented evidence or literature review precedes any drafting.
• A defined population of practitioners, assessors, or national bodies is consulted before a draft is finalized — never informally, and never optional.
• Conflict of interest is managed through a named, independent reviewer — never left to self-assessment alone.
• A specific, accountable body owns final approval, distinct from the group that drafted the revision.

6. Crosswalk: ASF Procedures Mapped to WHO, ISO, and ISQua

The table below maps every substantive ASF procedure, defined in full in Part III of this manual, to its direct equivalent — or closest analogue — in each of the three foundational methodologies. It exists so that a reader, an ASF Council member, or an external reviewing body such as ISQua itself can verify, at a glance, that no procedure in this manual was invented without precedent.

Part III — The ASF International Standards Council

7. Mandate, Structure, and Scope of Authority

The Council's governance is structured consistently with ISO 37000:2021, Governance of Organizations — the first international standard specifically addressing organizational governance, applicable to associations and non-profit bodies as much as commercial ones [39]. ISO 37000 organizes governance around a defined set of principles: clear purpose, aligned strategy, effective oversight, accountability at every level, genuine stakeholder engagement, and the strategic, responsible use of data [39]. Each of these principles has a specific, binding expression in this Section and in Section 8.

7.1 Standing Council and Revision Panels

The Council operates at two levels. A standing Council body — comparable in function to WHO's Guideline Review Committee and ISQua's Accreditation Council — holds ultimate approval authority over every revision and meets on a regular schedule independent of any specific revision cycle. For each individual standard under revision, the Council convenes a dedicated Revision Panel — comparable to a WHO Guideline Development Group — drawn from the wider Council membership and, where relevant, external experts.

Consistent with ISO 37000's oversight principle, the standing Council maintains a documented internal control system: no Revision Panel decision becomes binding without standing Council review, and the standing Council itself periodically reviews whether its own procedures — including this manual — are being applied as intended, not merely assumed to be [39].

7.2 Three Tracks, One Council

Consistent with Section 1.4, the standing Council governs all three of ASF's standard-types — organizational standards, the ASF Surveyor Training Standard, and the ASF Training & Education Standards — under a single structure. This is a deliberate accountability choice: a single, named body is ultimately responsible for the integrity of ASF's entire standards portfolio, rather than separate structures that could develop inconsistent practices independently. Part IV of this manual sets out the specific respects in which Revision Panel composition and process differ across these tracks; where Part IV is silent, this Part III governs all three identically.

7.3 Scope of Authority

The standing Council's authority extends to: approving or declining planning proposals (Section 12, Stage 2); approving, amending, or rejecting a Revision Panel's completed draft (Section 12, Stage 6); determining a revision's formal outcome — confirm, amend, revise, or withdraw (Section 12, Stage 6); hearing appeals not decided by an independent panel under Section 14; and reviewing this manual itself on the same three-year cycle it prescribes for ASF's published standards (Section 15).

The standing Council's authority does not extend to conducting facility, program, or professional assessments against ASF's published standards — a function kept organizationally separate under the principle stated in Section 2.4.

7.4 Revision Panel Composition

Every Revision Panel, whether working on an organizational or a training standard, includes at minimum: a panel chair, proposed by the standing Council and confirmed by panel agreement — mirroring WHO's own co-chair selection practice — who must be free of any relevant conflict of interest for the full duration of the revision; clinical, technical, or (for training standards) instructional-design experts with direct, current experience of the setting the standard governs, drawn from multiple countries and healthcare systems, not a single region; at least one representative with lived experience of the setting — as a patient, resident, service user, or, for a training standard, a learner who has genuinely completed comparable training — rather than as a professional within it; and a methodologist responsible for the evidence review described in Section 12, Stage 3.

7.5 External Review of the Council

A body that accredits others carries a genuine obligation to be independently reviewed itself, not merely to state that it is. Consistent with ISQua EEA’s own requirement, effective from October 2025, that organizations hold both standards accreditation and organizational accreditation together, not either alone [37], ASF submits this manual and the Council’s actual practice under it for independent external review by ISQua EEA on a cycle no longer than the revision cycle it governs — no less often than every three years.

External review specifically examines whether the Council’s documented procedures — conflict of interest management, quorum and voting, field consultation and pilot testing, appeals — are genuinely followed in practice, not only described in this manual. Findings are addressed in the same Annual Activity Report defined in Section 13.

8. Human Resources — Council and Panel Membership

This section governs the terms under which any individual serves as a member of the standing Council or a Revision Panel, from eligibility through to resignation or removal.

8.1 Eligibility Criteria

Eligibility for Council or Revision Panel membership is assessed against the criteria in Annex C (Member Selection Scoring Rubric): relevant technical or clinical expertise, or direct lived experience of the setting a standard governs; and, for standing Council membership specifically, a demonstrated understanding of ASF's methodology as set out in this manual. Consistent with Section 2.2, eligibility is never restricted by nationality, institutional affiliation, or prior relationship with ASF.

8.2 Terms of Service

1. Standing Council members serve a term of three years, aligned with the standard revision cycle, renewable once by mutual agreement between the member and the standing Council.

2. Revision Panel members serve for the duration of the specific revision to which they are appointed, concluding at Publication (Section 12, Stage 7) unless the same individual is separately reappointed to a subsequent revision.

3. No individual serves as panel chair for two consecutive revisions of the same standard, to ensure a genuinely fresh review perspective at each cycle.

8.3 Remuneration and Expenses

Council and Revision Panel service is voluntary and uncompensated, consistent with ASF's status as a non-profit association under the French law of 1 July 1901. Reasonable, documented expenses directly incurred in service — travel to an in-person panel meeting, where one is convened, and equivalent documented costs — are reimbursed by ASF on submission of receipts, subject to a per-revision budget approved by the standing Council in advance.

8.4 Code of Conduct

Every Council and Revision Panel member signs the Code of Conduct and Confidentiality Undertaking (Annex E) before beginning service. The Code requires: adherence to this manual's procedures in full; respectful, professional conduct toward fellow panel members, ASF staff, and field consultation participants; prompt disclosure of any change in circumstances affecting a prior conflict of interest declaration (Section 10); and non-use of Council or panel membership for personal or institutional promotional purposes without ASF's prior agreement.

8.5 Confidentiality Obligations

Draft standards, field consultation submissions not yet published in summary form, and any personal data disclosed in a conflict of interest declaration (Section 10, Annex A) are confidential until the standing Council formally publishes the relevant revision or consultation summary. This obligation survives the end of a member's term.

8.6 Resignation, Removal, and Succession

1. Resignation. A Council or Revision Panel member may resign at any time by written notice to the standing Council. Where the resignation affects a panel's composition requirements under Section 5.2, the standing Council initiates a targeted call under Section 9 to fill the specific seat vacated.

2. Removal. A member may be removed by standing Council decision for: a confirmed, disqualifying conflict of interest not disclosed at the required time; a material breach of the Code of Conduct (Annex E); or sustained non-participation materially affecting a revision's timeline. Removal requires the documented agreement of at least two standing Council members who were not involved in raising the matter.

3. Succession. Where a standing Council seat becomes vacant mid-term, a successor is selected under the same Call and Selection Procedure (Section 9) and serves the remainder of the original three-year term before their own term begins.

9. The Call and Selection Procedure

Membership of the Council, and of individual Revision Panels, follows a formal call procedure modeled directly on WHO's own practice of drawing GDG candidates from a standing roster combined with an open call for expressions of interest [29].

9.1 The Call Procedure

1. Announcement. The standing Council issues a public call for expressions of interest (Annex B), published through ASF's own channels (france-asf.fr, publichealth.ge, gmj.ge) and circulated to ASF's existing national and institutional partners. The call specifies the standard(s) under revision, the expertise and lived-experience perspectives being sought, the expected time commitment under Section 8.2, and the closing date.

2. Open eligibility. The call is open to any practitioner, institution representative, or individual with lived experience of the relevant healthcare setting, in any country — not limited to existing ASF partners or Georgian applicants, consistent with Section 2.1.

3. Roster maintenance. In parallel with each specific call, the Council maintains a standing roster of prior applicants, panel members, and referred experts — mirroring WHO's own roster of advisers [29] — subject to the retention limits in Section 11.3.

4. Submission. Candidates submit a short statement of relevant expertise or lived experience, a current curriculum vitae or equivalent, and a preliminary conflict of interest declaration (Annex A) as part of the application itself, not after selection.

9.2 The Selection Procedure

1. Initial screening. A designated Council officer reviews all submissions against the specific expertise and lived-experience criteria stated in the call, and confirms completeness of the required conflict of interest declaration.

2. Conflict of interest pre-screening. Before substantive scoring begins, preliminary declarations are reviewed by the Council officer together with a second, independent Council member — mirroring WHO's two-person severity review [35] — to identify any candidate whose declared interests would disqualify them from this specific panel.

3. Structured scoring. Eligible candidates are scored against the criteria in Annex C: relevant technical or clinical expertise; direct lived experience of the setting, where applicable; geographic and health-system diversity relative to the existing panel composition; and prior contribution to field consultation or standards development, where relevant.

4. Panel composition review. The standing Council reviews the scored candidate list as a group, not only individually, to confirm the panel as a whole meets the composition requirements in Section 7.4 — including the mandatory lived-experience seat and genuine geographic diversity, and reviewed specifically for the indirect discrimination risk described in Section 2.2.

5. Appointment. Selected candidates receive a formal Appointment Letter (Annex D) and are asked to confirm their final, complete conflict of interest declaration before the panel's first meeting. Unsuccessful candidates are, with their consent, added to the standing roster described in Section 9.1(3).

6. Onboarding. Before the panel's first meeting, each appointed member signs the Code of Conduct and Confidentiality Undertaking (Annex E), completing the human-resources requirements of Section 8.4 and 8.5 in a single, documented step.

10. Conflict of Interest Policy

ASF's conflict of interest policy is informed directly by the Guidelines International Network's Principles for Disclosure of Interests and Management of Conflicts in Guidelines [24], by WHO's own declaration and severity-review practice [18, 33, 35], and by documented findings on how such policies succeed and fail in comparable organizations [25–27].

A conflict of interest is any financial, professional, or personal interest that might reasonably lead an independent observer to question whether a Council or panel member's judgment on a specific revision is influenced by something other than the evidence and the standard's actual purpose. This includes direct financial interests (employment, consulting fees, equity) and indirect or non-financial interests (academic advancement, institutional affiliation, personal relationships with an affected organization) [24].

The policy proceeds from a specific, evidence-based conclusion: disclosure alone is not sufficient management of conflict of interest [24]. ASF's policy accordingly requires:

1. Mandatory written disclosure. Every candidate completes a written declaration (Annex A) at application, and every confirmed panel member updates it before the panel's first meeting and if circumstances change during the revision.

2. Verbal restatement at the first meeting. Following WHO's practice [33], each panel member verbally restates their declared interests at the panel's first meeting, in front of the full panel — logged in that meeting's minutes (Annex F).

3. Two-person documented assessment, not self-certification. A designated Council officer, together with a second independent Council member, determines whether a declared interest constitutes a genuine conflict for that specific revision — mirroring WHO's technical-officer-and-departmental-director model [35], and addressing a documented weakness found in nearly 80% of comparable organizations' policies, which lack explicit criteria for this determination [26].

4. Recusal for confirmed conflicts. A member with a confirmed conflict of interest does not participate in deliberation or voting on the affected revision.

5. A stricter standard for panel leadership. The chair of a revision panel and the methodologist responsible for its evidence review must be free of any relevant conflict of interest for the full duration of that revision.

6. Public record. Confirmed conflicts and recusals are recorded in the revision's Decision Record (Annex J), consistent with the transparency principle stated in Section 2.3.

11. Data Protection and Confidentiality of Applicant Information

As a France-registered association, ASF's processing of personal data submitted by Council and Revision Panel candidates — including the Conflict of Interest Declaration (Annex A) and any curriculum vitae or supporting material submitted under the Call Procedure (Section 9) — is governed by the EU General Data Protection Regulation (GDPR) and, in France specifically, by the guidance of the Commission Nationale de l'Informatique et des Libertés (CNIL).

11.1 Lawful Basis

ASF processes candidate data on the lawful basis that it is necessary for the steps a candidate has themselves requested, prior to any appointment: reviewing an application against the eligibility criteria in Section 8.1 and the scoring rubric in Annex C. Where ASF wishes to retain an unsuccessful candidate's data on the standing roster described in Section 9.1(3) beyond the standard retention period in Section 11.3, this requires the candidate's separate, explicit, freely given consent — obtained through an affirmative action, never a pre-checked box, and never made a condition of the original application.

11.2 Data Minimization

The Call Procedure (Annex B) and Conflict of Interest Declaration (Annex A) request only the information genuinely necessary to assess eligibility, expertise, lived experience, and conflicts of interest. Where a candidate discloses information that constitutes special category data under GDPR — for instance, a health condition disclosed as relevant lived experience, or an interest disclosure touching on a protected characteristic — that specific information is subject to enhanced access restriction beyond the standard protection in Section 11.4, limited strictly to the Council officer and independent second reviewer named in Section 10, item 3.

11.3 Retention

Unsuccessful candidates' application data, including conflict of interest declarations, is retained for a documented, purpose-based period, consistent with the absence of a single fixed EU-wide retention rule and with French CNIL guidance specifically permitting candidate-pool retention of up to two years where justified. ASF's default retention period is twelve months from the close of the relevant call, extendable to a maximum of twenty-four months only where the candidate has given the explicit, separate consent described in Section 11.1 to remain on the standing roster. Data is deleted or irreversibly anonymized at the expiry of the applicable period.

11.4 Access and Security

Candidate data is accessible only to the Council officer responsible for the relevant call, the independent second reviewer required under Section 10, and, where a candidate is selected, the standing Council members directly involved in that candidate's Revision Panel. A candidate may request access to, correction of, or deletion of their own data at any time; ASF responds to such requests within thirty days.

12. The Revision Cycle

Each ASF standard is formally reviewed on a three-year cycle — more frequent than ISO's mandatory five-year systematic review [19], and closely comparable to ISQua's four-year cycle [10]. The cycle proceeds in seven stages, each producing the specific document identified in Part V, Section 18.

Stage 1 — Scoping

Before evidence review begins, the Revision Panel drafts a scope for the revision, recorded in the Scoping / Planning Proposal Form (Annex G) — identifying, for each affected criterion, the specific question the revision must answer, framed where practicable in a Population–Setting–Comparator–Outcome structure adapted from WHO's PICO format [29, 34]. Where a revision affects multiple criteria with different real-world importance, the Panel ranks them using the 1-to-9 scale adapted directly from WHO's outcome-ranking practice [29, 32].

Stage 2 — Planning proposal and initial Council gate

The completed Annex G is submitted to the standing Council, mirroring WHO's own practice of gating a guideline at the planning stage, not only at final approval [17, 35]. The gate decision — approve, request changes, or decline — is recorded directly on Annex G and logged in that meeting's minutes (Annex F).

Stage 3 — Evidence review

A structured review of relevant literature, regulatory change, and field experience since the standard's last revision [10, 15–16]. Where a specific criterion rests on graded clinical or public-health evidence, the Revision Panel applies GRADE-informed reasoning — explicit consideration of evidence certainty [15–16, 18, 30].

Stage 4 — Drafting

Revisions are drafted by the Revision Panel, mirroring the working-group structure used by ISO's Technical Committees and WHO's Guideline Development Groups [15, 20–23].

Stage 5 — Field consultation

Before any revision is finalized, the draft is circulated to practitioners actually using the standard, with responses collected via the Field Consultation Response Form (Annex H) and remaining open for a minimum of thirty days. At the close of consultation, the Panel prepares a Consultation Summary Report (Annex I), documenting how feedback from each represented country or setting was genuinely considered — not merely received.

Written consultation alone is not sufficient. Following the pilot-testing discipline both HSO and ISQua apply before finalizing a revision [5–8, 10–11], the Revision Panel identifies at least two organizations of different scale or resource level — for an organizational standard, this means facilities; for a training standard, this means training providers or learners — to apply the revised criteria in practice, not merely comment on the text. Pilot results are included in the Consultation Summary Report (Annex I) alongside written feedback. A revision with no pilot-tested evidence that the criteria are genuinely workable in practice does not proceed to Stage 6.

Stage 6 — Council approval and revision outcome

The standing Council formally reviews the Consultation Summary Report, including pilot results, and approves the final revision, recording its decision on the Revision Decision Record (Annex J). Following ISO’s own systematic review framework [19], every revision cycle concludes with one of four formal outcomes: Confirm, Amend, Revise, or Withdraw, defined in Annex J itself.

Approval requires a quorum of at least two-thirds of standing Council members and the affirmative vote of at least two-thirds of members present, mirroring ISO’s own approval threshold for a Draft International Standard [20, 21]. Where quorum is not met, the decision is deferred to the next scheduled Council meeting rather than decided by whoever happens to be present.

Two further requirements apply to every Stage 6 decision. First, the Revision Panel explicitly documents the revision’s anticipated effect on equity — whether the change is more, less, or equally achievable for a well-resourced facility compared with one operating in a resource-constrained or conflict-affected setting — as part of the Revision Decision Record, not left implicit. Second, where a Council member votes against the majority decision, that dissent, and its stated reasoning, is recorded in the Revision Decision Record alongside the outcome. A unanimous record that never shows a documented disagreement is not evidence of genuine consensus; it is evidence that dissent was not captured.

Stage 7 — Publication and version control

The revised standard is published in full, with a clear version number and effective date, per Section 15. Every prior edition remains publicly documented and accessible rather than quietly superseded.

13. Reporting Requirements

Consistent with ISO 37000's accountability principle — that accountability is demonstrated through reports, disclosures, effective stakeholder engagement, and applying improvements, not merely asserted [39] — this section names every report the Council produces, its required frequency, its audience, and the annex or section that governs its content. No report in this manual exists only as a general commitment to transparency.

13.1 The Annual Activity Report

The standing Council produces one consolidated Annual Activity Report, covering: every revision cycle active or completed during the year, with its outcome (Annex J); a summary of field consultation reach — number of respondents and countries represented — without disclosing individual respondent identity; any conflicts of interest confirmed and their management (Section 10); any appeals received and their resolution (Annex L); and Council and Revision Panel membership changes, including any removal under Section 8.6.

14. Appeals and Disputes

ASF maintains a documented process for organizations, practitioners, or Council members to appeal a specific revision decision — informed by the requirement under ISO 17021-1:2015 that accreditation bodies maintain a documented process to receive, evaluate, and decide on appeals and complaints [28].

1. Grounds for appeal. An appeal may be filed on the grounds that field consultation feedback was not genuinely considered (Section 12, Stage 5, and Annex I), that a conflict of interest was not properly managed (Section 10), or that the revision materially departs from the evidence reviewed at Section 12, Stage 3. Grounds are stated on the Appeal Submission Form (Annex K).

2. Submission. Appeals are submitted in writing, using Annex K, within thirty days of a revision's publication (Section 12, Stage 7), specifying the grounds above and the specific Revision Decision Record (Annex J) being contested.

3. Independent review. The appeal is assigned to standing Council members who were not part of the original Revision Panel, consistent with the impartiality principle underlying comparable accreditation appeals processes [28]. Where the standing Council itself lacks sufficient uninvolved members — for instance, on a small or specialized standard — the Council may draw an independent reviewer from the standing roster described in Section 9.1(3), subject to the same conflict of interest screening required under Section 10.

4. Decision and record. The reviewing panel's decision, and its reasoning, is documented on the Appeal Decision Record (Annex L) and shared with the appellant. Where an appeal is upheld, the affected standard returns to Section 12, Stage 4 (Drafting) for the specific content in question — not to Stage 1, since the original scope and planning proposal are not themselves reopened unless the appeal's grounds specifically require it.

15. Document Control and Version Management

The revised standard is published in full, with a clear version number and effective date, following ISO's own publication and version-control discipline [21–22].

15.1 Version Numbering

ASF standards use whole-number versioning (Version 1, Version 2, Version 3) for a Revise or Withdraw outcome under Section 12, Stage 6, and decimal versioning (e.g., Version 3.1) for an Amend outcome — a limited, specific correction that does not reopen the standard's substantive content. A Confirm outcome retains the existing version number and resets only the review date.

15.2 Archiving

Every prior published edition of every ASF standard remains publicly accessible on ASF's own platforms (france-asf.fr, publichealth.ge) indefinitely, consistent with the transparency principle in Section 2.3. A superseded edition is clearly marked as such, with a direct reference to its replacement.

15.3 Translation and Multilingual Publication

Where an ASF standard is published in more than one language, the version number and effective date are identical across all language editions. In the event of a genuine discrepancy between language editions, the English-language edition is authoritative, and the discrepancy is corrected in the next scheduled revision or, where the discrepancy is substantive, through an out-of-cycle Amend.

15.4 This Manual's Own Version Control

This manual is itself subject to the same three-year review cycle it prescribes for ASF's published standards, under the same procedures set out in Sections 9 through 14. This is Version 4, published June 2026.

Part IV — Training and Education Standards

This Part makes explicit what Section 1.4 established in outline: ASF governs training and education standards under the same Council, the same core methodology, and the same document chain as its organizational standards — with the specific differences set out in this Part, and nowhere else.

16. How Training Accreditation Differs from Organizational Accreditation

Training and education standards are grounded in a distinct international reference beyond WHO, ISO's general standards process, and ISQua: ISO 21001:2025, Educational Organizations — Management Systems for Educational Organizations, the first international standard specifically dedicated to educational management [41]. Where ASF's organizational standards govern a facility's structures, processes, and safety, training standards govern a genuinely different subject: whether a course, curriculum, or educational program actually produces the competence it claims to produce.

16.1 What Is Assessed Differs

An organizational standard assesses a facility directly — its equipment, its staffing, its documented processes, observed at a physical site. A training standard assesses a program: its curriculum design, the alignment between stated learning outcomes and actual assessment methods, and evidence of learner competence achieved, not merely course completion recorded.

16.2 Scoping Differs: Outcomes Before Content

ISO 21001 requires that educational programs define learning outcomes first — what a learner should know and be able to do — before content is selected and sequenced, learning activities are designed, and assessment methods are chosen to align with those same outcomes [41]. ASF's Scoping stage for a training standard (Section 12, Stage 1, as adapted here) follows this same order: the Revision Panel defines the specific competence a criterion is meant to verify before drafting the criterion's actual language, rather than describing a training activity and inferring a competence from it after the fact.

16.3 Curriculum Review Cycles

Documented practice in educational accreditation places regular curriculum review at a 3-to-7-year interval, or per the applicable accrediting body's own requirement [41]. ASF's three-year cycle, defined in Section 12, sits at the more frequent end of this documented range — consistent with the same reasoning already applied to ASF's organizational standards in Section 12's introduction.

16.4 The Accreditor-of-Accreditors Layer

ISO has itself recognized that accrediting an educational organization is a genuinely distinct function from managing one: ISO/TS 21030:2023 sets requirements specifically for bodies that audit and certify educational organizations against ISO 21001 — developed jointly by ISO's conformity-assessment committee (CASCO) and its education and learning committee (TC 232) [42]. This is a direct, structural precedent for ASF's own position: the Council does not deliver training itself, and does not manage GMJ Academy's own curriculum; it accredits training programs — including, but not limited to, programs delivered through GMJ Academy — against ASF's own published training standards, maintaining the same independence from delivery that Section 2.4 requires between standards development and assessment generally.

16.5 Relationship to GMJ Academy

GMJ Academy is ASF's own continuing education platform, and a genuine potential subject of training accreditation — but not a privileged one. A course delivered on academy.gmj.ge is assessed against ASF's published training standards on exactly the same basis as a training program from any other provider, in any other country, consistent with Section 2.1's founding principle. Where GMJ Academy itself submits a course or program for ASF accreditation, ordinary conflict-of-interest procedure under Section 10 applies in full: any Council or Revision Panel member with an institutional affiliation to GMJ Academy discloses it, and the same two-person severity review determines whether that affiliation disqualifies them from that specific assessment.

16.6 International Recognition: The UNESCO Global Convention

ASF's training and education standards are further informed by UNESCO's Global Convention on the Recognition of Qualifications concerning Higher Education (2019) — the first United Nations treaty on higher education, in force since March 2023 [43]. The Global Convention establishes an internationally agreed definition of quality assurance: an ongoing process by which the quality of an educational system, institution, or programme is assessed by the competent authority to assure stakeholders that acceptable standards are continuously maintained and enhanced [43]. This definition is consistent with, and reinforces, the revision discipline set out in Section 12 of this manual.

Two elements of the Global Convention are directly relevant to ASF's own commitment. First, it explicitly requires “recognition for all,” including refugees and displaced persons — the same population ASF's Health & Migration endorsement is built around [43]. Second, it is implemented through national and regional organizations for accreditation and qualification frameworks, the same layered structure — national context, international framework — that governs how ASF's own standards apply across different countries' health systems.

16.7 ILO Standards on Vocational Training and Certification

The International Labour Organization's Human Resources Development Convention, 1975 (No. 142), requires ratifying states to develop policies and programmes of vocational guidance and training closely linked to employment, including provision for persons with disabilities [44]. Its companion instrument, the Human Resources Development Recommendation, 2004 (No. 195), updates this framework specifically around education, training, and lifelong learning — and introduces, as a core principle, the certification of skills as a right connected to decent work, not merely an administrative outcome of completing a course [45].

This principle — that certification represents a genuine, verified skill rather than attendance — is the same distinction Section 16.1 draws between course completion and demonstrated competence. ASF's training standards accordingly require evidence of achieved learning outcomes, consistent with ILO Recommendation No. 195's framing of certification as a substantive right, not a credential issued by default [45].

16.8 Continuing Professional Development, Distinct from Continuing Medical Education

ASF's training standards distinguish Continuing Professional Development (CPD) from Continuing Medical Education (CME), following the World Federation for Medical Education's Global Standards for Continuing Professional Development (2024) [46]. CME is a component of CPD, not a synonym for it: CPD is the broader, ongoing learning journey of a healthcare professional across their career, while CME typically refers to more formally structured, credit-bearing educational activity within that journey [46].

WFME's own standards deliberately decline to mandate a single CPD model, given genuinely wide variation across countries — some recognize only planned, formal activity such as courses and seminars; others also recognize unplanned, self-directed learning such as case discussion with colleagues, serving as a peer reviewer, or structured reading [46]. ASF's training accreditation accommodates both models: a training standard under this manual may certify a formal course or program (the CME-adjacent case) or a structured CPD framework built around portfolio-based, self-directed learning, provided the same outcomes-before-content discipline in Section 16.2 is genuinely applied in either case.

16.9 Qualification Portability

A training or education credential accredited under this manual is issued specifically against ASF’s published training standard for that program, not against any single country’s national qualification framework. Consistent with UNESCO’s Global Convention, portability is not automatic across borders [43]; it is the responsibility of the recognizing country’s own competent authority to determine whether an ASF-accredited credential satisfies its own requirements.

ASF’s own role, consistent with the Global Convention’s implementation structure, is to make that determination genuinely possible: every ASF training accreditation decision is published with the specific competencies assessed and the evidence standard applied, in a form a national recognition authority can actually evaluate — not merely a credential name and a date. This does not guarantee recognition in any given country. It ensures that where a country chooses to recognize an ASF-accredited credential, it can do so on a transparent, evidenced basis rather than trust alone.

17. The Training Standards Revision Panel

A Training Standards Revision Panel follows the identical call, selection, conflict-of-interest, revision-cycle, and document-chain procedures set out in Parts III and V of this manual. The following composition requirements apply in addition to, not instead of, Section 7.4.

17.1 Composition Differences

Where Section 7.4 requires clinical and technical experts with direct experience of the healthcare setting a standard governs, a Training Standards Revision Panel requires, at minimum:

• An instructional design or educational-methodology expert, with genuine experience in curriculum design and learning-outcome assessment — not a clinical role alone
• A subject-matter expert in the specific clinical or public-health domain the training addresses
• A learner representative — an individual who has genuinely completed comparable training, fulfilling the lived-experience seat required under Section 7.4 in a form specific to this track
• The panel chair and methodologist requirements of Section 7.4 apply identically

17.2 Field Consultation Population

Field consultation for a training standard (Section 12, Stage 5) specifically includes training providers, learners who have completed comparable programs, and employing healthcare organizations that rely on the training's stated outcomes — a genuinely distinct consultation population from the practitioners consulted on an organizational standard, reflecting Section 16.1's basic distinction between what is being assessed.

17.3 Current Status

ASF's training and education standards are published as ASF Training & Education Standards (ASF-TRAIN-STD-v1), developed and approved by the Council following the full procedure set out in this manual. This Part governs that standard's ongoing revision under the same three-year cycle applied to ASF's organizational standards, consistent with Section 1.4's commitment that no ASF procedure exists only as a described intention.

Part V — The Full Document Chain

18. The Complete Lifecycle, Document by Document

Every procedure described in Parts I through IV of this manual produces, or depends on, an actual document. This section sets out the complete chain, in the order it actually occurs, from the first public call through to a published, version-controlled standard — and, where a revision is contested, through to a resolved appeal. Each step names the governing section of this manual and the specific annex it produces or relies on.

18.1 The Chain, Step by Step

1. Call Published → Annex B (§9.1)

2. Application Submitted, with Preliminary COI Declaration → Annex A (§9.1(4))

3. Selection Scoring → Annex C (§9.2(3))

4. Appointment Letter Issued → Annex D (§9.2(5))

5. Code of Conduct Signed → Annex E (§9.2(6), §8.4)

6. Panel's First Meeting — Verbal COI Restatement → Annex F (§10, item 2)

7. Scoping and Planning Proposal Drafted → Annex G (§12, Stage 1)

8. Standing Council Gate Decision → logged in Annex F

9. Evidence Review and Drafting → §12, Stages 3–4

10. Field Consultation Opens — Responses Received → Annex H (§12, Stage 5)

11. Consultation Summary Report Prepared → Annex I (§12, Stage 5)

12. Standing Council Approval and Outcome Decision → Annex J (§12, Stage 6)

13. Publication and Version Control → §12, Stage 7; §15

Where a published revision is contested:

14. Appeal Submitted → Annex K (§14, item 2)

15. Independent Review by Uninvolved Council Members → §14, item 3

16. Appeal Decision Recorded → Annex L (§14, item 4)

References

1. Joint Commission. Standards. Oakbrook Terrace (IL): The Joint Commission; 2026.
2. American Hospital Association. Joint Commission standards receive significant updates. AHA News. 2025.
3. Joint Commission. Standards field reviews. Oakbrook Terrace (IL): The Joint Commission; 2026.
4. Circa Behavioral Health. Joint Commission January and July 2026 updated standards for behavioral health. 2026.
5. Health Standards Organization. The 7 steps of the standards development process. Ottawa: HSO; 2020.
6. Health Standards Organization. About HSO. Ottawa: HSO; 2026.
7. Accreditation Canada. About Accreditation Canada. Ottawa: Accreditation Canada; 2026.
8. Standards Council of Canada. How national standards are developed. Ottawa: SCC; 2025.
9. ISQua External Evaluation Association. ISQua EEA publishes the 6th edition of the Guidelines and Principles for the Development of Health and Social Care Standards. Dublin: ISQua; 2026.
10. International Society for Quality in Health Care. Guidelines and Principles for the Development of Health and Social Care Standards, 4th edition. Dublin: ISQua; 2018.
11. International Society for Quality in Health Care. Guidelines and Principles for the Development of Health and Social Care Standards, 5th edition. Dublin: ISQua; 2017.
12. CARF International. Our Standards. Tucson (AZ): CARF International; 2026.
13. CARF International. Introduction to CARF Accreditation. Tucson (AZ): CARF International; 2018.
14. We Want Relief. What is CARF accreditation and why does it matter? 2025.
15. World Health Organization. Guideline development process. In: WHO Guideline on Self-Care Interventions for Health and Well-Being, 2022 revision. Geneva: WHO; 2022.
16. World Health Organization. Methodology and process for development of the guideline. In: WHO Consolidated Guideline on Self-Care Interventions for Health. Geneva: WHO; 2021.
17. Going into the black box: a policy analysis of how the World Health Organization uses evidence to inform guideline recommendations. 2024.
18. World Health Organization. WHO Handbook for Guideline Development, 2nd edition. Geneva: WHO; 2014.
19. International Organization for Standardization. Guidance on the Systematic Review Process in ISO. Geneva: ISO; 2021.
20. International Organization for Standardization. Stages of the development of International Standards. Geneva: ISO; 2024.
21. International Organization for Standardization. Stages and resources for standards development. Geneva: ISO; 2026.
22. Understanding ISO standards: development process and publication types. 2026.
23. Stratlane. The role of ISO technical committees in standard development. 2026.
24. Guidelines International Network. Principles for disclosure of interests and management of conflicts in guidelines. Ann Intern Med. 2015;163(7):548-553.
25. Managing conflicts of interest in the UK National Institute for Health and Care Excellence (NICE) clinical guidelines programme: qualitative study. PLOS One. 2015.
26. Policies on conflicts of interest in health care guideline development: a cross-sectional analysis. 2016.
27. Conflict of interest disclosures for clinical practice guidelines in the National Guideline Clearinghouse. PLOS One. 2013.
28. ISO 17021-1:2015. Conformity assessment — Requirements for bodies providing audit and certification of management systems — Part 1: Requirements, sections 9.7–9.8 (Appeals and Complaints). Geneva: ISO; 2015.
29. World Health Organization. Guideline development process. In: Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services. Geneva: WHO; 2017.
30. World Health Organization. Scoping meeting for the WHO guideline on the prevention and treatment of wasting in infants and children. Geneva: WHO; 2020.
31. World Health Organization. Guideline development process. In: Management of Physical Health Conditions in Adults with Severe Mental Disorders. Geneva: WHO; 2018.
32. World Health Organization. The WHO guideline development process. In: Transforming and Scaling Up Health Professionals' Education and Training. Geneva: WHO; 2013.
33. World Health Organization. Guideline development process. In: WHO Guideline on the Use of Safety-Engineered Syringes for Intramuscular, Intradermal and Subcutaneous Injections in Health Care Settings. Geneva: WHO; 2016.
34. World Health Organization. Guideline development process. In: Guideline: Sugars Intake for Adults and Children. Geneva: WHO; 2015.
35. World Health Organization. Guideline development process. In: Improving Early Childhood Development: WHO Guideline. Geneva: WHO; 2020.
36. World Health Organization. Methods for guideline development. In: WHO Guideline for the Clinical Management of Exposure to Lead. Geneva: WHO; 2021.
37. International Labour Organization. Discrimination (Employment and Occupation) Convention, 1958 (No. 111). Geneva: ILO; 1958.
38. ISQua External Evaluation Association. Health and Social Care Standards — Assessment Methodology. Dublin: ISQua EEA; 2026.
39. International Organization for Standardization. ISO 37000:2021, Governance of Organizations — Guidance. Geneva: ISO; 2021.
40. United Nations. Convention on the Rights of Persons with Disabilities. New York: UN; 2006.
41. International Organization for Standardization. ISO 21001:2025, Educational Organizations — Management Systems for Educational Organizations — Requirements with Guidance for Use. Geneva: ISO; 2025.
42. International Organization for Standardization. ISO/TS 21030:2023, Educational Organizations — Requirements for Bodies Providing Audit and Certification of Educational Organizations Management Systems. Geneva: ISO; 2023.
43. UNESCO. Global Convention on the Recognition of Qualifications concerning Higher Education. Paris: UNESCO; 2019.
44. International Labour Organization. Human Resources Development Convention, 1975 (No. 142). Geneva: ILO; 1975.
45. International Labour Organization. Human Resources Development Recommendation, 2004 (No. 195). Geneva: ILO; 2004.
46. World Federation for Medical Education. WFME Global Standards for Continuing Professional Development. Ferney-Voltaire: WFME; 2024.

Annex A — Conflict of Interest Declaration Form

To be completed by every candidate at the time of application, and updated and re-signed before the first meeting of any Revision Panel on which the individual serves.

Full name: __________________________________________________

Organization / institutional affiliation: __________________________________________________

Country: __________________________________________________

Standard(s) or revision(s) for which this declaration applies: __________________________________________________

Section 1 — Direct Financial Interests

Disclose any current or recent (within the past 3 years) employment, consulting arrangement, board membership, equity holding, or direct payment from any organization with a genuine interest in the outcome of this revision.

Section 2 — Indirect and Non-Financial Interests

Disclose any academic, institutional, or professional interest — including pending publications, institutional affiliation with an affected organization, or a close personal relationship with someone holding a direct interest — that might reasonably be seen to influence your judgment.

Section 3 — Declaration

☐ I confirm the above is a complete and accurate statement of my relevant interests as of the date below.

☐ I understand that ASF's Council will independently assess whether any declared interest constitutes a conflict for this specific revision, and that this determination is not left to my own self-assessment.

☐ I agree to update this declaration immediately if my circumstances change during the revision.

Signature: ________________________________________

Date: ________________________________________

For Council Use Only — Independent Assessment

Reviewed by (Council officer): ________________________________________

Co-reviewed by (independent second Council member): ________________________________________

☐ No conflict identified — candidate may participate without restriction

☐ Manageable conflict identified — see management plan attached

☐ Disqualifying conflict identified — candidate may not serve on this Revision Panel

Date of assessment: ________________________________________

Annex B — Call for Standards Council Members (Template)

Accréditation Sans Frontières — Call for Revision Panel Members

Standard(s) under revision: __________________________________________________

Call opens: ______________________________

Call closes: ______________________________

ASF's International Standards Council is convening a Revision Panel for the above standard(s), as part of its regular three-year revision cycle. We are seeking applications from:

• Clinical and technical professionals with direct, current experience in the relevant healthcare setting
• Individuals with lived experience of the relevant setting — as a patient, resident, family member, or service user
• Practitioners from a range of countries and health-system resource levels; we specifically welcome applications from outside ASF's existing partner network

Expected time commitment: [to be specified per revision — typically evidence review participation, one panel meeting, and review of the field consultation draft].

To apply, submit: a short statement of relevant expertise or lived experience (max. 300 words); a current curriculum vitae or equivalent summary; and a completed preliminary Conflict of Interest Declaration (Annex A).

Applications not selected for this specific revision are retained, with consent, on ASF's standing roster of candidates for consideration in future revisions.

Annex C — Member Selection Procedure and Scoring Rubric

This annex sets out the working scoring rubric a Council officer uses at Section 9.2, Step 3 of this manual.

Scoring Criteria (each scored 0–3)

1. Relevant technical or clinical expertise — direct, current experience in the setting the standard governs.

2. Lived experience — direct personal experience of the setting as a patient, resident, or service user, where applicable to the specific seat being filled.

3. Geographic and health-system diversity — the candidate's country and health-system context relative to the panel's existing composition.

4. Prior contribution — documented prior participation in field consultation, standards development, or comparable work.

A candidate scoring 0 on Criterion 1 or 2 for the specific seat being filled is not eligible for that seat regardless of total score. Composition review (Section 9.2, Step 4) takes priority over individual ranking: the standing Council may select a lower-scoring candidate over a higher-scoring one specifically to meet the mandatory lived-experience seat or genuine geographic diversity requirement in Section 7.4.

Annex D — Appointment Letter Template

Candidate name: _____________________________________________

Standard(s) / revision(s): _____________________________________________

Role: ______________________________

☐ Standing Council member

☐ Revision Panel chair

☐ Revision Panel member

☐ Methodologist

Term of service (§8.2): _____________________________________________

On behalf of the ASF International Standards Council, we are pleased to confirm your appointment to the above role. This appointment is subject to:

• Your completed, confirmed Conflict of Interest Declaration (Annex A)
• Your signed Code of Conduct and Confidentiality Undertaking (Annex E)
• The terms of service set out in Section 8.2 of How ASF Develops and Revises Standards, Version 4

Expected time commitment: _____________________________________________

Expenses policy applicable (§8.3): ______________________________

Issued by (Council officer): ________________________________________

Date: ______________________________

Annex E — Code of Conduct and Confidentiality Undertaking

I undertake to:

☐ Adhere in full to the procedures set out in How ASF Develops and Revises Standards, Version 4

☐ Conduct myself respectfully and professionally toward fellow panel members, ASF staff, and field consultation participants

☐ Promptly disclose any change in circumstances affecting my Conflict of Interest Declaration (Annex A), for the full duration of my service

☐ Not use my Council or panel membership for personal or institutional promotional purposes without ASF's prior written agreement

☐ Keep confidential all draft standards, unpublished field consultation submissions, and any personal data of fellow candidates or members disclosed to me in the course of this service, both during and after my term (§8.5)

☐ Recuse myself from deliberation or voting on any matter where a conflict of interest has been confirmed under Section 10

Full name: _____________________________________________

Role: ______________________________

Signature: ________________________________________

Date: ______________________________

Annex F — Meeting Minutes Template

Standard(s) / revision(s): _____________________________________________

Meeting number / date: _____________________________________________

Format: ______________________________

☐ In person

☐ Virtual

☐ Hybrid

Chair: ________________________________________

Members present: ____________________________________________________________

Members absent: ____________________________________________________________

Conflict of Interest Restatement (first meeting only)

Record, for each member present, confirmation that declared interests were verbally restated and no change has occurred since the written declaration.

Agenda Items and Decisions

Actions and Owners

Minutes prepared by: ________________________________________

Date circulated: ______________________________

Annex G — Scoping / Planning Proposal Form

Standard(s) under revision: _____________________________________________

Revision Panel chair: _____________________________________________

Scope of This Revision

For each affected criterion, state: the population or facility type affected; the current requirement or practice in question; any alternative or comparator practice identified; and the specific outcome this criterion is intended to protect.

Outcome Ranking (1–9 scale, §3.2)

List each affected criterion with its ranked importance: 7–9 (critical), 4–6 (important), 1–3 (not critical to this revision).

Standing Council Gate Decision

☐ Proposal approved as submitted

☐ Proposal approved with requested changes to scope (attached)

☐ Proposal declined — reasoning attached

Decided by: ________________________________________

Date: ______________________________

Annex H — Field Consultation Response Form

Respondent name: _____________________________________________

Organization (if any): _____________________________________________

Country: _____________________________________________

Standard(s) under consultation: _____________________________________________

Response

Specific criterion or section this response addresses:

Nature of comment:

☐ Support as drafted

☐ Support with suggested amendment

☐ Concern — practical or operational

☐ Concern — evidence or accuracy

Detail:

How the issue you raise is currently handled in your own healthcare setting (optional, but genuinely useful to the Panel):

Date submitted: ______________________________

Annex I — Consultation Summary Report Template

Standard(s) under consultation: _____________________________________________

Consultation period: _____________________________________________

Total responses received: ______________________________

Countries / settings represented: _____________________________________________

Summary by Criterion

For each criterion receiving substantive comment: number of responses, nature of concerns raised, and the Panel's proposed response (accept, partially accept, decline with reasoning).

Overall Assessment

Panel's overall assessment of whether consultation feedback was genuinely considered, and what changed as a result.

Prepared by: ________________________________________

Date: ______________________________

Annex J — Revision Decision Record

Standard(s) revised: _____________________________________________

Revision Panel chair: _____________________________________________

Consultation Summary Report reference (Annex I): _____________________________________________

Pilot testing organizations (minimum 2, per §12 Stage 5): ____________________________________________________________

Quorum and Vote

Standing Council members eligible / present: ________________________________________

Votes in favor / against / abstain: ________________________________________

☐ Quorum met (at least two-thirds of eligible members present)

Equity Impact

Anticipated effect of this revision on facilities or programs operating in resource-constrained or conflict-affected settings, relative to well-resourced settings.

Dissent, If Any

Any Council member voting against the majority decision, and their stated reasoning.

Outcome (§12, Stage 6)

☐ Confirm — standard republished unchanged, review date reset

☐ Amend — limited, specific correction, substantive content not reopened

☐ Revise — substantive technical revision

☐ Withdraw — standard retired

Conflicts of Interest Recorded This Revision

Per Section 10, item 6 — list any confirmed conflicts and resulting recusals.

New version number: ______________________________

Effective date: ______________________________

Approved by (standing Council): _____________________________________________

Date of decision: ______________________________

Annex K — Appeal Submission Form

Appellant name: _____________________________________________

Organization (if any): _____________________________________________

Standard and revision being appealed: _____________________________________________

Revision Decision Record reference (Annex J): _____________________________________________

Grounds for Appeal (§14, item 1 — select all that apply)

☐ Field consultation feedback was not genuinely considered

☐ A conflict of interest was not properly managed

☐ The revision materially departs from the evidence reviewed at Stage 3

Detail

Submitted: ______________________________

Received by (Council officer): ________________________________________

Annex L — Appeal Decision Record

Appeal reference (Annex K): _____________________________________________

Reviewing Council members (not involved in original revision): ____________________________________________________________

Decision

☐ Appeal upheld — affected standard returns to Stage 4 for the specific content in question

☐ Appeal partially upheld — details below

☐ Appeal not upheld — original decision stands

Reasoning

Decision shared with appellant on: ______________________________

Decided by: ________________________________________

Date: ______________________________

Annex M — Source Documents Used in Developing ASF's Standards

International legal and normative instruments

• United Nations. United Nations Principles for Older Persons. General Assembly resolution 46/91. New York: UN; 1991.
• United Nations. Single Convention on Narcotic Drugs, 1961, as amended by the 1972 Protocol. New York: UN; 1972.
• World Health Organization. Refugee and Migrant Health: Global Competency Standards for Health Workers. Geneva: WHO; 2021.

National legal and regulatory sources

• Georgia. Order №4/ნ of the Minister of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs, 26 January 2023. On Approval of the Conditions for International Accreditation of Medical Service Providers. Tbilisi: Legislative Herald of Georgia (matsne.gov.ge); 2023.

Clinical and public health evidence

Each ASF standards document maintains its own complete Vancouver-style reference list, specific to the clinical, safety, and operational evidence underlying its individual criteria. These are published in full within each respective standard: Hospital, Ambulatory Clinic, Long-Term Care, Primary Health Clinic, Fitness & Wellness, Telemedicine, and Home Care Standards, Version 3, 2026.

Annex N — Glossary

• Council — The ASF International Standards Council, defined in Part III.
• Revision Panel — The dedicated working panel convened for a specific standard's revision, defined in Section 7.1 and 7.4.
• Conflict of interest — Defined in Section 10.
• Field consultation — The mandatory practitioner-review stage defined in Section 12, Stage 5.
• GRADE — Grading of Recommendations Assessment, Development and Evaluation; the evidence-certainty framework referenced in Section 3.4 and applied throughout Section 12.
• Standard-type — Organizational, surveyor training, or training and education; the three areas of ASF accreditation activity defined in Section 1.4.
• PICO / Population-Setting-Comparator-Outcome — The structured question format described in Section 3.2 and adapted for ASF's own scoping stage in Section 12, Stage 1.
• Revision cycle — The seven-stage, three-year process defined in Section 12.

This manual governs every ASF standard currently published — organizational and, as it develops, training and education — and will itself be reviewed by the ASF International Standards Council on the same three-year cycle it describes.

Index

Alphabetical, correlated to page number.

AMSTAR 9, 13

Annual Activity Report 16, 23

Appeal 5, 7, 13, 15, 16, 23, 24, 31, 32, 44, 45

Appointment Letter 18, 31, 37

Code of Conduct 17, 18, 31, 37, 38

Confidentiality 17, 18, 20, 37, 38

Conflict of interest 5, 9, 12, 13, 15, 16, 17, 18, 19, 20, 24, 32, 34, 35, 37, 38, 39, 44, 47

Consultation Summary Report 21, 23, 31, 42, 43

Council officer 18, 19, 20, 23, 31, 34, 36, 37, 44

Data protection 20, 23

Direct discrimination 7, 18

Discrimination 7, 18, 33

Dissent 21, 43

Equity 9, 19, 21, 34, 43

Evidence review 9, 13, 15, 21, 24, 31, 35, 44

External review 10, 13, 15, 16

Field consultation 7, 13, 16, 17, 18, 21, 23, 24, 29, 31, 35, 36, 38, 41, 42, 44, 47

GMJ Academy 5, 27

GRADE 9, 13, 21, 47

Guideline Development Group 9, 15, 21

Guideline Review Committee 10, 13

HSO 7, 21, 32

ILO 7, 12, 16, 21, 28, 33, 43

Indirect discrimination 7, 18

ISO 17021 13, 24, 32

ISO 21001 27, 33

ISO 37000 15, 23, 33

ISQua 12, 13, 15, 17, 18, 21, 27, 32, 33, 34

Lived experience 17, 18, 20, 35, 36

Meeting Minutes 23, 39

Mirror committee 11, 13

P-member 11, 13

PICO 9, 13, 21, 47

Pilot testing 12, 16, 43

Planning proposal 9, 13, 15, 21, 24, 31, 40

Quorum 16, 21, 43

Recusal 19, 43

Revision cycle 7, 10, 15, 17, 21, 23, 29, 35, 47

Revision Decision Record 21, 23, 24, 43, 44

Revision Panel 5, 7, 15, 17, 18, 19, 20, 21, 23, 24, 27, 29, 34, 35, 37, 38, 39, 40, 42, 43, 47

Scoping 9, 13, 21, 27, 29, 31, 32, 40, 47

Selection Procedure 7, 13, 17, 18, 36

Standing Council 15, 17, 18, 20, 21, 23, 24, 31, 36, 37, 39, 40, 43

Steering Group 9, 10, 13

Systematic Review 9, 10, 11, 13, 21, 32

Technical Committee 11, 21, 32

Three-year cycle 10, 11, 15, 21, 27, 47

Training standard 15, 21, 27, 28, 29

UNESCO 27, 28, 33

Version control 21, 25, 31

Vote 11, 13, 21, 43

WFME 28, 33